EmailMe Form - Application for Residents at Derbyshire House

Applicant's name *
First Last
Likes to be called
Former Occupation
Marital status
Religion
Present address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone
Email
Birth place
Date of birth *
National Insurance No. *
NHS No. *
Please note:
We will need you to provide documentation of all medications and the reasons for taking this medication and any underlying health problems that you may have.
Name of doctor
Medical Practice *
Address of Medical Practice *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Contact details for next of kin
Name (next of kin) *
Address (next of kin) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (next of kin)
Email (next of kin)
Does this person hold power of attorney?
Does this person have a lasting personal welfare power of attorney? (The home will need to be provided with copies of these if available)
Name address and telephone number of two other family members or friends that could be contacted in an emergency.
Name (family member 1)
Address (family member 1)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (family member 1)
Name (family member 2)
Address (family member 2)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (family member 2)
Solicitor details
Solicitor Name
Solicitor (Practice name)
Address (Solicitor)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (Solicitor)
References
Name, address and telephone number of two persons of standing who have known you well for several years (other than relatives)
Name (Reference 1)
Address (Reference 1)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (Reference 1)
Name (Reference 2)
Address (Reference 2)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone (Reference 2)
Emergency Contact
Name (contact) *
Address (contact) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone (contact) *
Email
Application notes
Is this application urgent?

Will you be funding yourself?

Will you require local authority funding?
Notes
Please note that if you are self-funding, you must be able to fund your stay at Derbyshire House for a minimum of 5 years. If you are unable to do this and need to apply for funding from the local authority then a third party top-up is mandatory to the relevant fee required. It is in your best interests to contact your Local Authority Social Services Department for an assessment of your care needs whether you are self-funding or seeking Local Authority funding. If you are only able to self-fund your stay for a limited period of time, the Local Authority will not automatically fund your residency unless a Social Worker has assessed that you are in need of Residential care. The funding you receive from the Local Authority may not be sufficient to cover your agreed fees and may require a third party top-up by your family /representative.
Declaration
I have read the Service Users Guide and am happy with the services offered to me, and understand my commitment to pay the agreed fees for my residency at Derbyshire House.
Signature of applicant (Paper applications)
Name of applicant (Online applications)
Date Time
MM / DD / YYYY

Is this application urgent?
Will you be funding yourself?
Will you require local authority funding?

Please note:

Contact details for next of kin

Name address and telephone number of two other family members or friends that could be contacted in an emergency.

Solicitor details

References

Emergency Contact

Application notes